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No.6463094
Narne QAP_~~,__~~~~~_
residing aL __§;!'J._J!~g!l__~~.!J __~:!-fP~~~J__~C!!-_
Age l.L6.y ears.Date of order of adrnission __l!QY~Q~r_J..1 __~J.4Q_
Date certificate issued ~9Y_~~!"_~3 J_J.~~§by the
___9~~~!l_R.~E!~Court aL '!f~~J!~!t~~~~L?_~!_
Petition No.__-"-~15 _
Alien Registration NO~l~~~__~~
(Complete and true signature of holder)